VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Alpha House II
3903 West Autumn Drive
Petersburg, VA 23803
(804) 861-0533

Current Inspector: Irvin Goode (804) 543-5188

Inspection Date: March 29, 2023 and May 16, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-151 Administration 22VAC40-151 Residential Environment 22VAC40-151 Programs and Services 22VAC40-151 Programs and Services 22VAC40-151 Disaster or Emergency Planning 22VAC40-80 The License

Technical Assistance:

Discussed admission procedures as noted in Standards for Licensed Children?s Residential Facilities - 22 VAC 40-151-570.A.1-5.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/29/23 from 10:30 AM ? 6:55 PM: Inspection conducted simultaneously with the Alpha House I - Monitoring inspection 3/30/23 from 2:15 PM ? 6:59 PM: Inspection conducted simultaneously with the Alpha House I - Monitoring inspection 3/31/23 from 12:03 PM ? 6:12 PM: Inspection conducted simultaneously with the Alpha House I - Monitoring inspection 4/5/23 from 3:07 PM ? 4:54 PM: Preliminary Findings Meeting conducted for both facilities. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents in care at the beginning of the inspection: 2 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident?s records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: An unannounced renewal inspection was completed by the Licensing Specialist on the previously mentioned dates and times. The following is a listing of the activities for this inspection: Reviewed one current resident record and one discharged resident record. Reviewed medication administration records. Two personnel records were reviewed. One staff member and one resident were interviewed. An inspection of the interior and exterior of the facility was completed. Other documentation reviewed during this inspection included, but was not limited to the following: emergency drill documentation, menus, and staff work schedules. The Program Director was available and accessible during the inspection. The Program Director participated in the preliminary findings meeting held at the facility on 4/5/23. An exit meeting was conducted on 5/16/23 to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Michele Freeman, Licensing Inspector at (804) 662-7062 or by email at michele.freeman@dss.virginia.gov

Violations:

Standard #:	22VAC40-151-120-B
Description:	Violation: Based on review of the facility?s policy and procedure for the written decision-making plan and interview with staff, the facility failed to comply with the intent of the plan. Findings: Due to a limited number of characters in this field, the findings for this violation are on a separate document. These findings are available for review by submitting a Virginia Freedom of Information Act Request.
Plan of Correction:	The Director of Alpha House will revise the change of command for Alpha House no later than June 1, 2023.
Standard #:	22VAC40-151-740-B
Description:	Violation: Based on review of the current resident?s, CR1?s, record, the facility failed to ensure the resident had a screening assessment for tuberculosis (TB) within seven days of placement. Findings: 1) Upon review of CR1?s TB screening assessment dated for 1/19/23, it is incomplete. Therefore, the resident?s TB status is unknown. 2) S3 was interviewed on 4/5/23 about this form. S3 acknowledged this form is incomplete.
Plan of Correction:	The resident in question did have a TB screening performed on the same day as the intake physical. Physical form was checked resident communicable disease free, however; the physician signed but did not check the block on the assessment form indicating resident was TB free, This is an error that should have been caught the staff as quality assurance checks were being done regarding program documentation. The importance of leaving no blanks on documents was reviewed during staff meeting on May 18, 2023 by the director.
Standard #:	22VAC40-151-750-E
Description:	Violation: Based on review of current resident?s, CR1?s, medication administration record and interview with staff, the facility failed to demonstrate a medication was administered as prescribed. Findings: 1) The medication administration record (MAR) has a box for staff to initial and note the time for each day of the month that medication is given. 2) In addition, the ?Alpha House Policy and Procedure for Medication? states the following ? ?Alpha House shall maintain a medication administration record of all medicines received by each resident and shall include: 1. Date the medication was prescribed; Drug name; 3. Schedule for administration; 4. Strength of medication; 5. Route; 6. Identity of individual who administered the medication; 7. Date the medication was discontinued or changed.? 3) The MAR for March 2023 for medication, M1, shows empty boxes on the following dates: 3/7 and 3/8. 4) This MAR was discussed with staff, S3, on 3/29/23. S3 acknowledged the MARs were incomplete, which demonstrates the medication was not administered as prescribed.
Plan of Correction:	Medication administration policy, and practices including medication error documentation requirements was reviewed with all staff during an in person staff meeting May 18, 2023. It was stressed during the meeting that medications must be administered as directed by the ordering physician and staff administering the medication must sign the medication book acknowledging the medication was administered or a medication error was completed. Staff writing in the shift log that medications were administered must be accompanied by individual resident medication sheets sign by the staff member administering medication. Overnight staff was reminded that they are our quality assurance staff and should be double checking daily for medication refills, medication log book log for accuracy/ signatures, as well as print documents, and review progress notes, task sheets, etc.
Standard #:	22VAC40-151-830-B
Description:	Violation: Based on review of the facility?s policy for ?Pharmacological or Mechanical Restraints? and interview with staff, the language used in this document permits the use of pharmacological restraints, which is prohibited by the standards. Findings: 1) A document titled, ? Chemical or Mechanical Restraints? was provided by staff, S3, during this inspection as an updated policy and procedure document on 3/29/23. The footer of this document states the following ? ?Revised 2023.? 2) This facility?s document uses ?Chemical? in lieu of ?Pharmacological.? 3) This version of the document supports the use of mechanical restraints and states the following ? ?The use of mechanical restraints is prohibited except as permitted by other applicable state regulations or as ordered by a court of competent jurisdiction.? 4) S4 was interviewed on 4/5/23 during the preliminary findings meeting about this document. S4 acknowledged this statement was noted on this document. 5) The Licensing Specialist advised S3 that mechanical restraints are prohibited. 6) On 4/6/23, S3 emailed the Licensing Specialist another version of this document that includes this topic. S3 addressed this document was reviewed with staff in November 2022 and the document presented on 3/29/23 was shared in error. However, this version of the document allows the use of pharmacological restraint, which states the following - ?The use of chemical restraints are administered only with written direction and and (sic) supervision of a licensed medical professional. Instructions for medication administration and / or medication therapy shall be followed as ordered by the physician.?
Plan of Correction:	Alpha House Prohibitions were rewritten by the director to conform to the standards. Copy of new document is attached.
Standard #:	22VAC40-151-840-A
Description:	22 VAC 40-151-840 Violation: Based on review of the facility?s policy document titled, ?Behavior Interventions,? and interview with staff, the facility failed to include all of the required elements. Findings: Due to a limited number of characters in this field, the findings for this violation are on a separate document. These findings are available for review by submitting a Virginia Freedom of Information Act Request.
Plan of Correction:	The Alpha House Behavior intervention plan will be revised by the Director no later than June 1, 2023; to allow for all staff to participate in the Crisis wave training that is schedule for May 25 and May 26, 2023.